MUSCLE INJURY GUIDE:

PREVENTION OF AND RETURN TO

PLAY FROM MUSCLE INJURIES

MUSCLE
INJURY
GUIDE: 1

Prevention of
and Return to
Play from
Muscle Injuries
Editors: Senior Editorial
Ricard Pruna Assistant:
Thor Einar Andersen Steffan Griffin
Ben Clarsen
Alan McCall Editorial Assistant:
Johann Windt

CHAPTER 1
SECTION FC BARCELONA
LEADERS CONTRIBUTORS

Clare Ardern Juanjo Brau

Roald Bahr Xavi Linde
Aaron Coutts Antonia Lizárraga
Maurizio Fanchini Sandra Mecho
Phil Glasgow Edu Pons
Tero Jarvinen Jordi Puigdellivol
Lasse Lempainen Xavi Valle
Andrea Mosler Xavi Yanguas
James O’Brien
Tania Pizzari
Nicol van Dyk
Markus Waldén
Arnlaug Wangensteen EXERCISE-BASED
MUSCLE INJURY
PREVENTION (EBMIP)
GROUP (see section
1.4.4a)
INTERNATIONAL
CONTRIBUTORS Andrea Azzalin
Andreas Beck
Abd-elbasset Abaidia Andrea Belli
Khatija Badhur Martin Buchheit
Natalia Bittencourt Gregory Dupont
Mario Bizzini Maurizio Fanchini
Ida Bo Steenhal Duccio Ferrari Bravo
Martin Buchheit Shad Forsythe
Phil Coles Marcello Iaia
Aaron Coutts Yann-Benjamin Kugel
Michael Davison Imanol Martin
Gregory Dupont Samuele Melotto
Caroline Finch Jordan Milsom
Brady Green Darcy Norman
Martin Hägglund Edu Pons
Shona Halson Stefano Rapetti
Joar Harøy Bernardo Requena
Per Hölmich Roberto Sassi
Franco Impellizzeri Andreas Schlumberger
Gino Kerkhoffs Tony Strudwick
Ozgur Kilic Agostino Tibaudi
Justin Lee
Matilda Lundblad
Nicolas Mayer
Robert McCunn
Tim Meyer DESIGNER AND
Haiko Pas PUBLISHER
Noel Pollock
Janne Sarimo FCB Marketing
Anthony Schache Department
Andreas Serner
Karin Silbernagel
Adam Weir
Jonas Werner
Nick van der Horst Muscle Injury Guide:
Anne D van der Made Prevention of and
Return to Play from
Muscle Injuries ©
FC BARCELONA, 2018.
BARÇA INNOVATION HUB
Muscle Injury
Guide:
Prevention of
and Return to
Play from
Muscle Injuries

Editors: Senior Editorial

Ricard Pruna Assistant:
Thor Einar Andersen Steffan Griffin
Ben Clarsen
Alan McCall Editorial Assistant:
Johann Windt
Summary
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
E. Editor’s biographies
0. Introduction to
the Guide
0.1 PREVENTING AND TREATING MUSCLE
INJURIES IN FOOTBALL
0.2 PARTNERSHIP WITH OSLO SPORTS
TRAUMA RESEARCH CENTRE
0.3 SCIENCE AND MEDICINE IN FOOTBALL
JOURNAL’S SUPPORT
0.4 A LETTER OF SUPPORT FROM DR MICHEL
D’HOOGE
0.5 INTERNATIONAL COLLABORATORS
1. General Principles of
Preventing Muscle Injury
1.1.1. AN INTRODUCTION TO PREVENTING MUSCLE
INJURIES.DOCX
1.1.2 A NEW MODEL FOR INJURY PREVENTION IN
TEAM SPORTS: THE TEAM-SPORT INJURY
PREVENTION (TIP) CYCLE
1.2.1 EVALUATING THE MUSCLE INJURY SITUATION
1.2.2 EVALUATING THE MUSCLE INJURY SITUATION
IN YOUR OWN TEAM
1.3.1 RISK FACTORS AND MECHANISMS FOR
MUSCLE INJURY IN FOOTBALL
1.3.2 THE COMPLEX, MULTIFACTORIAL AND
DYNAMIC NATURE OF MUSCLE INJURY
SUMMARY
1.3.3 MUSCULOSKELETAL SCREENING IN FOOTBALL
2. General Principles
1.3.4 BARRIERS AND FACILITATORS TO DELIVERING of Return to Play from
INJURY PREVENTION STRATEGIES
Muscle Injury
1.4.1 STRATEGIES TO PREVENT MUSCLE INJURY
2.1.1 RETURN TO PLAY FROM MUSCLE INJURY:
1.4.2 CONTROLLING TRAINING LOAD AN INTRODUCTION
P7
2.1.2 RETURN TO PLAY IN FOOTBALL: A DYNAMIC
1.4.3 RECOVERY STRATEGIES MODEL
P8
2.1.3 ESTIMATING RETURN TO PLAY TIME
1.4.4A EXERCISE-BASED STRATEGIES TO
PREVENT MUSCLE INJURIES P 10
2.2.1 MAKING AN ACCURATE DIAGNOSIS
1.4.4B EXERCISE SELECTION FOR THE MUSCLE P 13
INJURY PREVENTION PROGRAM 2.3.1 EXERCISE PRESCRIPTION FOR MUSCLE INJURY
P 24
2.3.2 RESTORING PLAYERS’ SPECIFIC FITNESS AND
1.4.4C EXERCISE SELECTION: HAMSTRING PERFORMANCE CAPACITY IN RELATION TO
INJURY PREVENTION MATCH PHYSICAL AND TECHNICAL DEMANDS
P 29
1.4.4D EXERCISE SELECTION: QUADRICEPS INJURY 2.4.1 REGENERATIVE AND BIOLOGICAL
PREVENTION TREATMENTS FOR MUSCLE INJURY
1.4.4E EXERCISE SELECTION: ADDUCTOR MUSCLE
P 38
2.4.2 SURGERY FOR MUSCLE INJURIES
INJURY
P 42
1.4.4F EXERCISE SELECTION:CALF INJURY
PREVENTION 3. RTP from Specific
1.4.5 COMMUNICATION
Muscle Injury
1.5 CONTINUOUS (RE)EVALUATION AND
MODIFICATION OF PREVENTION STRATEGIES 3.1 RETURN TO PLAY FOLLOWING HAMSTRING
MUSCLE INJURY
3.2 RETURN TO PLAY FOLLOWING QUADRICEPS
MUSCLE INJURY
3.3 RETURN TO PLAY FOLLOWING GROIN MUSCLE
INJURY
3.4 RETURN TO PLAY FOLLOWING CALF MUSCLE
INJURY
General
principles of
Return to Play
from Muscle
Injury
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.1.1

RETURN TO PLAY FROM MUSCLE

INJURY: AN INTRODUCTION
The previous section on preventing muscle injury in football has outlined various
strategies and tools that can be adopted to minimise the risk of players incurring
a muscle injury. While in an ideal world we would be able to prevent all muscle
injuries from occurring this is unfortunately, impossible. As outlined in our ‘Injury
Landscape’ article (1.2.1.) a professional football team can expect around 16 muscle
injuries in a season.
— With Ricard Pruna, Alan McCall and Thor Einar Andersen

As such we need to be optimally < 7

prepared to deal with muscle injuries Figure 1 Objectives
(and challenge) of
when they come. Following a muscle returning a player
injury (or any injury for that matter) from injury.
there are 2 main objectives (and at
the same time challenges); 1) to return
the player to match-play as soon as
possible and 2) to avoid re-injury.
There is a fine balance to this, which
is complex depending on the context
of each individual player, injury and
circumstance (figure 1).

In football, the decision to progress

or delay a players’ return to play
following muscle injury, could be the
difference between having a player
back two matches earlier (increasing
the chance to win 6 points) versus
keeping the player out an extra two
weeks, lowering his/her injury risk,
but maybe gaining fewer points
from those two matches.1 Essentially,
it comes down to a decision on an
agreed ‘level of risk’ (for re-injury)
that the team is willing to accept
i.e. a shared decision of medical,
performance practitioners, the coach
and the player him/herself.

The purpose of this chapter on ‘General

Principles of Return to Play from
Muscle Injury’, as with the previous
prevention section, is to bring together
the best of research knowledge and
demonstrate how we combine this
with our practical experience and
knowledge. Providing you with general
principle to follow during the return to
play process.

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.1.2

RETURN TO PLAY IN FOOTBALL:

A DYNAMIC MODEL
There is a paradigm shift occurring in the way we think about return to play.
Instead of return to play being the highly anticipated event occurring at the end of
a rehabilitation program, we now consider that return to play starts the moment
the injury occurs and continues beyond the point where the player is returning
to unrestricted match play (Figure 1). This type of progression is individual and
malleable, allowing for faster and slower individual progressions throughout the
return to play plan.
— With Clare Ardern and Ricard Pruna

8 Early and
accurate
Return to team
training (partial
Return to match
play (partial play /
<
diagnosis participation / lower duration)
Figure 1
modified) Football return to play
continuum (adapted
from Ardern et al.1)

Return to field Return to full Return

(individualised) team training to desired
(unmodified) performance

The concept of return to play as a

continuum was introduced in the Bern
2016 consensus on return to sport,1 and
is something familiar to FC Barcelona
clinicians and practitioners, who have
been practicing in this framework for
the past decade. The purpose of this
section is to outline 6 guiding principles
for return to football after muscle injury
and highlight 4 key considerations for
the decision-making team.
GUIDING PRINCIPLE 1
Making an accurate diagnosis is
the cornerstone of effective injury
management and return to play
planning. Accurate diagnosis facilitates
an estimation of prognosis, and in turn,
shared decision-making regarding
injury management. Imaging may be
used judiciously at this step, but you
must be clear about what (if anything)
imaging will do to change the return
to play plan.2 At FC Barcelona, we
work backwards from the anticipated
time to return to full match-play.
Understanding biology will help
when estimating injury prognosis and
planning a strategy for appropriate
loading through the return to play
continuum.
THE BARÇA WAY
Working backwards from an antici-
pated return to desired performance
date – which is usually a specific
game – helps motivate the player
and facilitates effective communi-
cation with the manager and per-
formance team. Progress towards
the goal is continuously assessed
using the milestones in the return to
play continuum. In this way we can
see whether the player is on track,
behind, or ahead of schedule.
GUIDING PRINCIPLE 2
Return to play plans must be tailored to the
individual player, who has an individual
injury and an individual return to play
continuum. An individualised plan is
responsive to the needs of the player to
appropriately consider factors that might
influence prognosis, and those that could
influence the risk for reinjury at any stage
through the return to play. A one-size-fits-
all approach is insufficient in professional
football, given the multifactorial nature
of return to play, and the need to address
specific individual factors based on the
player’s needs.
GUIDING PRINCIPLE 3
Appropriate loading throughout the
return to play continuum is important
to stimulate satellite cells to promote
muscle tissue healing, and (in later
stages of the return to play plan)
to ensure the player is adequately
prepared for the demands of return to
performance. Structuring the return to
play plan so that the player spends as
much time as possible doing football-
specific, pitch-based training (with
appropriate modification, according to
impairments and functional limitations)
provides two important benefits. First,
it facilitates appropriate and specific
loading (when combined with a
well-structured impairment-focused
(e.g. strength, flexibility.) management
plan). Second, maintaining contact
with the team provides the injured
player considerable psychosocial and
motivation support.

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

GUIDING PRINCIPLE 4 GUIDING PRINCIPLE 5 GUIDING PRINCIPLE 6

Use regular assessment and feedback
to reinforce and guide collaborative goal
setting. Repeat testing and monitoring
can help the player see progress, and
this is often especially helpful for players
with injuries that have extended time
loss. Continual assessment of players’
performance, in particular football-specific
actions such as repeated sprints and
external running loads as well as how they
are coping with these through internal load
markers (e.g. perceived exertion, fatigue,
soreness) and psychological readiness
and confidence, may help you and the
player monitor the progressive restoration
of strength, ability to perform football
actions and psychological readiness. The
information gathered from regular testing
can, in turn, guide goal setting about when
it is safe to resume restricted training,
unrestricted training and unrestricted match
play.
How you communicate with the injured
player is important. Focus on using
language that emphasises that return
to play is a progression that begins at
the time of injury. Return to play is not
something that automatically happens
once rehabilitation is completed. Use
positive language that focuses on what
the player can do – whether that is
modified individual field-based training,
modified team training, or performing as
desired in the competitive environment.
Focusing on the performance aspect
in each phase of the return to play
continuum is vital to helping the player
maintain the sense of being an athlete,3
irrespective of whether he or she has
achieved the goal performance, or not.
Keeping the player cognitively engaged
in football, even when off the pitch,
to maintain the high-level cognitive
function required for football is essential.
The unpredictable nature of football
requires high-level cognitive function for
reaction time, decision-making, shifting
attention, pattern recognition and
anticipation.4 Keeping the football brain
active helps the player stay engaged
in rehabilitation. Mental fatigue can
impact on performance,5 and training
cognitive function should be part of a
standard football conditioning program.5
Therefore, it is also appropriate to
include relevant cognitive challenges
throughout the return to play continuum.
Strategies to consider include choosing
typical football movement patterns or
skills where decisions have to be made
9
randomly and focusing on attention and
temporo-spatial control.

<
Figure 2
Football-specific
d high cognitive
demands while
performing rapid
changes of direction,
passing and shooting.
The player responds to
light signals indicating
running direction
and whether he/she
should pass or shoot.
This challenges both
the players’ spatial
awareness and
reaction times. In a
muscle injury with
6-week prognosis,
we would typically
introduce this drill
following the second
week.

FOUR KEY CONSIDERATIONS FOR EFFECTIVE RETURN TO PLAY PLANNING

1. Many factors influence the 3. Support the player to be 4. Return to play planning
return to play.1 Physical and confident about returning is about managing risk.7,
mental readiness to return to play by keeping him 8 Careful planning and
to play are both important or her involved with the regular monitoring will help
aspects, and do not always team throughout the return the decision-making team
go hand-in-hand. to play plan, by regularly appropriately consider risk
monitoring progress,6 and implement effective risk
2. Use a group of sport-
and by emphasising minimisation strategies for
specific functional tests and
football-specific elements timely return to play.
player-reported outcomes
throughout.
to monitor progression and
to judge when the player
is physically and mentally
ready to return to play.1

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.1.3

ESTIMATING RETURN
TO PLAY TIME
When a footballer sustains a muscle injury, their first question is invariably: “how
long will this take to recover?” Answering this is not easy,1-5 but in elite-level football
it is vital to make an educated guess. As previously discussed, the RTP continuum
begins with the anticipated date of return to optimal performance in mind and works
backwards, defining the milestones necessary to achieve that goal. This approach
motivates the player, allows the manager to plan effectively, and facilitates good
communication and realistic expectations from all involved.
— With Ricard Pruna and Ben Clarsen

10 Recent research has shown that, when
used in isolation, both MRI and clinical
assessment findings are poor predictors
of RTP time.1-5 That is because even
when the same type of injury occurs,
myriad individual and contextual
factors influence how quickly each
player will recover, and how much
risk the player and team are willing to
take. Nevertheless, it is our experience
that when experienced practitioners
consider a range of important factors
together, it is possible to estimate RTP
time surprisingly accurately.
THE FC BARCELONA
APPROACH
The foundation for any RTP estimate
is an accurate diagnosis. However, it
is also essential to consider player-
specific (intrinsic) factors, football-
specific (extrinsic) factors and other
risk tolerance modifiers. We highlight
that practitioners should continuously
re-evaluate the initial RTP estimation
throughout the rehabilitation process,
depending on how quickly the player
progresses along the milestones
defined in the RTP continuum. Key
indicators of whether the player is
on-target to meet the anticipated
RTP date include regaining baseline
strength and flexibility measures,
completing high-intensity training
sessions comparable to (or even
greater than) their anticipated match
demands, and demonstrating an
appropriate level of football-specific
cognitive skills and psychological
readiness.
THE STARTING POINT: LOCATION AND PLAYER-SPECIFIC FACTORS
EXTENT OF TISSUE DAMAGE
Every football player has unique anatomy
Knowing the exact injury location is that will affect his or her recovery from
arguably the most important factor in a muscle injury. For example, due to
predicting RTP time. This is why, at FC differences in free tendon length, a biceps
Barcelona, clinical assessments are femoris injury located 5cm from the
performed and high-quality MRI images ischial tuberosity might involve mostly
are taken as soon as possible after tendon tissue in one player, and muscle
muscle injuries occur. Knowing whether tissue in another. Careful examination of
any tendon or bony tissue is involved is each MRI image is therefore necessary.
vital, as injuries involving these tissues
generally heal more slowly and might Variations between players’ connective
need referral to a surgeon. In addition, it tissue quality may also affect an injury’s
is necessary to identify injuries to muscle recovery time. Although this may be
regions that are highly stressed during determined by genetic factors that we are
football, as these need to be managed currently unable to identify with certainty.
more conservatively than injuries located A history of frequent muscle injury can
in less-stressed regions. be a good indication of poor connective
tissue quality. More conservative RTP
Although the patient history often provides plans should therefore be made for
vital information towards making an frequently injured players.
accurate diagnosis, the initial amount of
pain and functional impairment can be
misleading when estimating RTP time.
Knowing where the injury is located and
which tissues are affected provides much
more information. For example, hamstring
strains located in the middle third of the
muscle belly are often severely painful
and cause a large haematoma, yet most
players return to desired performance
within one month – some as quickly as 3
weeks. In contrast, partial ruptures of the
proximal hamstrings tendons often initially
appear to be minor injuries; they are less
painful and their onset is less dramatic.
However, these injuries generally take far
longer to recover – often up to 10 weeks.
The expected return to play times for
specific injury locations in the hamstrings,
adductors, quadriceps and calf muscles
can be found later in this guide.

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
FOOTBALL-SPECIFIC FACTORS
Each player’s unique role on the
pitch needs to be considered when
estimating the RTP time. For example,
wide defenders and wingers perform
more high-speed running than
other players so hamstring injury
rehabilitation may take longer for
players in those positions. Similarly,
central midfielders frequently perform
rapid direction changes, which places
high demands on their adductor
muscles. Key positional demands and
their consequences for muscle injury
rehabilitation are summarised in Table 1.
Additionally, each player has a unique
playing style that may also affect his or
her RTP plan. For example, some players
have an aggressive style, chasing every
ball and pressing opponents throughout
the whole game. Others are more
tactical and therefore more economical
with their energy expenditure.
Finally, muscle injuries located in
players’ dominant and non-dominant
legs may have markedly different
recovery time, and even different
management plans. For example, partial
ruptures of the proximal rectus femoris
direct tendon are possible to treat
conservatively if they are in the non-
dominant leg, but the same injury in the
dominant leg is a clear case for surgery.
CHAPTER 2
POSITION KEY DEMANDS CONSEQUENCES FOR < 11
MUSCLE INJURY Table 1
Key positional
Goalkeepers, Long kicks and jumps High stress on rectus demands and
central defenders femoris their potential
consequences
on muscle injury
Full backs, High speed running, High stress on hamstrings
wingers rapid acceleration and rehabilitation
deceleration
Central Frequent direction High stress on soleus
midfielders changes
Strikers, High speed running, High stress hamstrings
attacking acceleration and and adductors
midfielders deceleration and
direction changes
RISK TOLERANCE MODIFIERS Importantly, the RTP decision is also
highly dependent on the level of re-
Whenever a player returns to football injury risk that the player and others
after a muscle injury, there is always a (e.g. medical and performance team,
risk that the injury will recur. Generally, team manager) are willing to take.
the sooner the player returns, the Will they accept a re-injury higher risk
higher the re-injury risk. However, it and return to play early, or reduce the
is impossible to know the exact risk risk by returning more slowly? This is
in each situation. Therefore, every RTP influenced by a wide range of contextual
decision is a “judgment call”, ideally factors called risk tolerance modifiers.7
made by the player, the medical team, These include factors directly related
and the coaching and performance team to football, such as the importance of
together.6 The decision is based on a the upcoming games, the importance
range of factors, such as: of the player, and the availability of
replacement players, as well as others
• Whether the injured tissues are such as financial factors (e.g. the player
likely to have healed sufficiently to is currently negotiating a new contract)
tolerate the loads of competitive or psychological factors (e.g. pressure
football from self, family, agents etc).
• Whether the milestones along the A number of risk tolerance modifiers, in
RTP continuum have been achieved particular those that are directly football-
related, can be identified as soon as
• If the player feels psychologically the injury occurs. These should be
ready to return considered when estimating RTP time.
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

12

PUTTING IT ALL TOGETHER PLAYER 1 PLAYER 2 <

Table 2
As illustrated in Table 2, making the RTP Example of how the
Injury location Biceps femoris tear Biceps femoris tear same injury can lead
estimate for a specific muscle injury and severity involving the intramuscular involving the intramuscular to markedly different
tendon rupture, located tendon rupture, located
involves adjusting the normally expected in the middle third of the in the middle third of the
RTP time estimates
RTP time upwards or downwards, based thigh thigh
on player-specific factors, football-specific
“Normal” RTP 4 weeks 4 weeks
factors, and risk-tolerance modifiers. time for this
injury
This process requires medical knowledge,
Player-specific 1st injury in this location 3rd injury in this location
football knowledge and experience, factors (no change to initial RTP (Indicates poorer quality
and should be considered an art just as estimate) connective tissue: +1 week)
much as a science. We highlight that
Football- Central midfielder, tactical Wing back, aggressive
throughout this section we have used the specific factors playing style (no change) playing style (High sprint
term estimation, rather than prediction. demands: +1 week)
None of us owns a crystal ball. However,
Risk-tolerance Key player in the team. Player not normally in
using a guiding framework can help even modifiers Injury occurred in starting 11. Injury occurred
inexperienced practitioners make more February, 3 weeks before in October (Lower risk
accurate and consistent RTP estimations. Champions League strategy: +1 week)
semi-final (Higher risk
acceptable: -1 week)

Estimated RTP 3 weeks 7 weeks

time

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.2.1

MAKING AN ACCURATE
DIAGNOSIS
When an injury occurs during training or match play, the essential questions to
answer as clinician on-field are: where is the localisation of the muscle injury, what
type is the injury and, can the player continue to play? In most cases, the player
should be taken off the field for further assessments and acute injury management
according to the PRICE principle (protection, rest, ice, compression, elevation).
— With Thor Einar Andersen, Arnlaug Wangensteen, Justin Lee, Noel Pollock, Xavier Valle

The first step off-field is a 13

comprehensive clinical examination MUSCLE INJURIES
including detailed patient injury
history taking and careful physical
assessments. In cases where the Macrotrauma Microtrauma
· Sudden onset Acute Overuse · Gradual onset
clinical appearance and severity
is unclear and determining the · Chronic compartment
optimal treatment can be difficult, · Delayed onset muscle
supplementary radiological imaging Non-contact Contact
soreness (DOMS)
· Focal tissue thickening /
can provide important additional (internal forces) (external forces) fibrosis
information to confirm the radiological
severity of the injury and guide
further treatment. Making an accurate Strain/tears Contusions
diagnosis is essential to ensure that · Tendon ruptures · Mytosis ossificans ^
· Avulsion fractures · Acute compartment Figure 1
injured players receive appropriate
Schematic overview
treatment and correct information Cramps Lacerations of the different types
regarding their prognosis.1 This chapter of muscle injuries.
Tendon and bone
will discuss the initial and subsequent injuries (avulsion
clinical and possible radiological fractures) are included
assessments to enable the clinician to as sub-classifications
of muscle strain
confirm an accurate diagnosis. injuries, as they
may appear to be
muscle injuries with
ON-FIELD MANAGEMENT similar mechanisms
and often similar
Working on-field as a clinician, with Signs that the player may be able to clinical presentation.
(Reprinted with
the pressure of limited time and the continue to play include, for example, permission from
requirement to act quickly when an muscle cramps that resolve quickly with Wangensteen 20182).
acute injury happens, the purpose of no residual symptoms, or mild contusion
the initial assessment is to answer some injuries with no loss of function and
important questions: Is there a muscle minimal pain. However, we encourage the
injury and where and what type is the practitioner to err on the side of caution. If in
injury? And can the player continue to doubt, take them out.
play or not?
The acute management should be initiated
Typical signs of an acute muscle injury as soon as possible. Despite little evidence
to identify include, an acute onset of basis for the early management of acute
pain where the player is able to recall muscle (strain) injuries3, the PRICE principle
the inciting event, pain or discomfort is traditionally considered the cornerstone
with isometric contraction, stretching, for treating acute soft tissue injuries.4,5
and palpation of the injured muscle. In POLICE (protection, optimal loading, ice,
many cases the range of motion (ROM) compression, elevation) is suggested as an
is restricted. In the section below, we alternative acronym, where optimal loading
present a guide on how to establish a means replacing rest with a balanced and
tentative diagnosis. incremental RTP program where early ≥

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

14 activity encourages early recovery.6 It
is important to initially differentiate
between contact and non-contact
injuries. In contusion injuries, such
as quadriceps contusions, the injured
muscle is recommended to be stretched
towards maximum during compression in
order to minimise hematoma formation
(by increasing the counterpressure),7–9
whereas muscle strain injuries should not
be elongated towards outer ranges during
the initial management to avoid additional
strain and damage.
Later in this section, we describe
specific clinical examination tests
for the most common muscle injury
locations in football – the hamstrings,
adductor, quadriceps and calf muscles.
The initial clinical examination
should be performed as soon as the
player leaves the field and with daily
follow-up examinations until the
correct diagnosis is established. In
the following section, we outline a
systematic approach to the clinical
examination of muscle injuries.
PATIENT HISTORY
A thorough injury history forms the
foundation of diagnosis. In fact, in
many cases it is possible to accurately
diagnose the injury based only on
the injury history. The most important
questions regarding the injury situation
and mechanism, symptoms, previous
injury history and workload are shown
in Table 1. More detailed information
specific to each muscle injury location
can be found later in this section.

OFF-FIELD EXAMINATIONS
Clinical examination, including patient
history taking and physical assessments,
is the cornerstone in the diagnosis of
any muscle injury and should be the first
step before any further investigations
are performed.10–12 The primary aim of
the clinical examination is to determine
the type, location and extent of the injury
and whether imaging and/or other
investigations are needed. In addition,
clinical examinations form the basis for
further RTP decisions, and are valuable
as the foundation for re-testing and
comparison when considering information
to be provided for the RTP decision-
making process. The clinical examination
may provide a rough estimate of the
severity and time needed to RTP, although
further evaluation and observation is likely
to increase the accuracy of this estimation.
Clinical assessment, in conjunction with
imaging, can also identify the rare cases
when early surgery is required.

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

<
Injury When did the injury occur? Table 1 15
situation General patient history
During game or training? (timing)
questions for muscle
First, middle or last part? (register minutes of the game) injuries
Season: beginning, middle, end, out of season
How did the injury occur? Injury mechanism
Contact or non-contact? (i.e. contusion or strain?)
Exact movement; high speed running – acceleration/deceleration (typically hamstring); kicking (typically adductor and
rectus femoris), stretching; changing directions/cutting; jumps/take offs/landings; towards excessive outer ranges (NB total
ruptures!)
Forced to stop immediately? Weightbearing impossible or restricted? (might indicate severity)
Able to continue? Able to continue with restrictions?
‘Popping’ feeling and/or sound at time of injury? (might indicate severity and suspicion of total rupture)

Pain Location (where does the player report pain)

Onset: acute or gradual?
Severity (a visual analogue scale or a numeric rating scale of 0-10 can be helpful):
• at the time of injury onset
• today (at time of examination)
• at rest
Time to pain free walking?
Function:
• pain with walking?
• pain with ascending/descending stairs?
• specific activity provoking pain?
Other aggravating factors?

Previous Is this a re-injury?

injury
Any feeling of tiredness/discomfort/pain last 7 days before injury onset?
history
Previous injury of same type (location) and side?
Previous injury of same type (location), other side?
Other muscle injury? (specify)
Other injuries and/or complaints
• low back pain
• fractures
• other

Workload Previous last training and games played (last week/month)

Intensity/workload last week/month

Other Initial treatment received

questions Factors that might influence general recovery – e.g. poor sleep, nutrition, recent long-haul flights

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16 PHYSICAL EXAMINATION
Gait and Walking:
function - antalgic gait pattern? The physical examination should
- need for crutches?
start with careful inspection and an
Jogging:
- able to jog? assessment of function, followed by
Other functional movements (observe ability to and quality, register pain):
palpation, active and passive ROM
- two leg squat testing, isometric pain provocation
- one-leg squat and muscle strength testing. Finally,
- trunk flexion (hamstrings)
- calf raises (gastrocnemius) additional tests (such as neural
- jumping, kicking and change of directions (minor injuries) sensitive structures, pulse etc.) can be
performed (Table 2). We recommend
Inspection Visible ecchymosis (bleeding / hematoma)
starting with the uninjured side,
Swelling?
as this provides the player with a
Visible disruption? reference as to what feels ‘normal’,
‘Bulk’ / ‘gap’? before examining the injured side.
Palpation Tenderness / pain provocation with palpation is useful for identifying the specific
Normally, pain experienced during
region/muscle injured, as well as the presence or absence of a palpable defect in the the different tests is recorded, where
musculotendinous junction. Importantly, detection of any discontinuity or ‘gap’ at the pain indicates a positive test and
proximal or distal tendinous insertion should lead to suspicion of a total rupture and
should be further investigated and confirmed or disproved by MRI. no pain indicates a negative test.
Location and length of pain
Visual analogue scales (VAS) or
numeric pain rating scales (NRS)13,14
Palpable disruption/discontinuity of muscle/tendon
are commonly used in order to
Insertional pain
quantify the player’s pain. Objective
Active and ROM is assessed as the presence of pain, the intensity of pain (VAS or NRS) and/or measurements, for example using
passive range objective in grades with goniometer/inclinometer (°). goniometers and HHD’s, might be
of motion
(ROM) testing
Active ROM: the player is asked to perform an active ROM exercise without assistant useful in order to quantify side-to-
and the restriction of ROM compared to unaffected side is registered. The tests depend
on the muscle suspected to be injured but are always instructed to be performed first
side differences or deficits, and to
with a slow motion, thereby with increased speed if appropriate. track progression during the RTP
Passive ROM: is used to elicit muscle stiffness/ assess muscle length. By applying excessive process. In section 3, specific physical
stress/overpressure at the end range, the test might reproduce the player’s symptoms. tests and objective measurements
for each of the specific muscle
Isometric The affected muscle or muscle group is tested isometrically at different ranges, commonly
pain by the clinician applying resistance that the player is asked to withstand. Often, a ‘brake’ injury locations are elaborated and
provocation test is performed at the end of the test (f.ex after 3 seconds) to assess the eccentric discussed.
component. The amount of force required to provoke pain can be quantified using a HHD.

Muscle Muscle strength of the affected muscles or muscle group is tested either manually or
strength/ objectively by HHD to detect any weakness / deficit compared to the unaffected side.
muscle
capacity

Neural The mobility of pain-sensitive neuromeningeal structures might be assessed by relevant <
tension tests neural tension tests related to the specific muscles or muscle groups tested. Straight Table 2
leg raises (SLR) and slump tests are for example used after hamstrings injuries, as Overview of general
involvement of the sciatic nerve is a potential source of pain in the posterior thigh. physical examination
tests for muscle
Other Clinical examination of the joints above and below the injury may provide injuries used to
information about contributing factors for the muscle injury. establish a diagnosis.
for muscle

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
IMAGING AND OTHER SUPPLEMENTAL
INVESTIGATIONS
Imaging investigations assist in
confirming the initial clinical diagnosis
and may help guide the RTP estimation.
Magnetic Resonance Imaging (MRI)
and ultrasonography are normally the
recommended modalities to assess
muscle injury, although X-ray and CT are
occasionally indicated.15,16
MRI
MRI using fluid-sensitive techniques
(fat-suppressed spin-echo T2 weighted) is
ideally suited since it allows the detection
of oedema and fibre disruption (tear) at
the site of the damage in the first hours
after the injury and to provide an objective
assessment of the intramuscular and
extra-muscular tendon of the muscle. MRI
provides a complete assessment of the
whole muscle-tendon-bone unit.15
At FC Barcelona, MRI is initially used
to identify the location and extent of
tissue damage. In addition, MRI is used
at specific time points during the RTP
process to ensure there is no increased
oedema or connective tissue gap (see
Section 3 – Return to Play from Specific
Muscle Injury)
CHAPTER 2
ULTRASONOGRAPHY
Ultrasonography of acute muscle injury
may be an alternative, or an adjunct to
MRI.15,16 Muscle oedema is not as reliably
delineated on ultrasonography as it is
on MRI and assessment of a retracted
tendon within a complex haematoma
may also be challenging. However,
ultrasonography is a higher spatial
resolution technique than MRI, and is
quicker and cheaper to perform.15 Most
importantly, ultrasonography allows
dynamic assessment of the muscle
injury. Ultrasonography can also be
used in follow up to assess haematoma
resorption and the early detection of
calcification.16
X-RAY AND CT
X-ray of the affected limb is indicated in
two situations:
1. When bony avulsion of the
tendon attachment is suspected.
This is particularly relevant to the
adolescent athlete where one
might suspect an apophyseal
avulsion injury.17,18 A cortical
avulsion may not be visible on
MRI as the fragment is often low
signal within a retracted low-
signal tendon.
2. Full-delineation of myositis
ossificans. CT scans may confirm
a diagnosis of myositis ossificans
following direct muscle trauma.15
The CT demonstrates classic
“egg-shell” appearance of the
calcification.
MUSCLE INJURY GRADING 17
AND CLASSIFICATION
SYSTEMS
Following the initial examinations,
clinicians commonly assign a grade
or classify the muscle injury based on
the clinical and/or radiological signs
and symptoms. An injury ‘classification’
refers specifically to describing or
categorising an injury (for example
by its location, injury mechanism
or underlying pathology), whereas
a ‘grade’ provides an indication for
clinical and/or radiological severity
of the injury.19 Using a grading
or classification may ease the
communication between clinicians.
Although there has been several
clinical and radiological grading- and
classification systems purposed for
muscle injuries, there are currently no
uniform approach or consensus to the
categorisation and grading of muscle
injuries.19,20 An overview of some
of the most common grading- and
classification systems purposed are
discussed below and summarized in
Tables 3 to 7. Radiological systems have
historically categorised muscle injuries
with simple grading systems based on
the severity/extent of the injury ranging
from 0-3 representing minor, moderate
and complete injuries,19,21–23 and
these have been widely used among
clinicians and researchers.24 The four
grade modified Peetrons classification
is based on an ultrasound ordinal
severity grading system,22 first described
for MRI findings after hamstring injuries
among European professional football
players in a ≥
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
18 larger study from the UEFA Elite Club
Injury Study.23 It has also been applied
for other muscle groups25 (see Table 3).
Radiological grading using modified
Peetrons have shown correlations
with lay-off time after acute hamstring
injuries23,26,27 and quadriceps injuries.26
However, this grading system
has been criticised for being too
simplistic, without considering the
anatomical location and specific tissue
involvement.19,28 Thus, the diagnostic
accuracy and prognostic value of these
grading systems are questionable19
and the prognostic value of MRI has
recently been reported as limited.29,30
New MRI classification systems
including both the extent (severity
grading) as well as the anatomical
site/location of the injury has been
proposed.28,31 For example, Chan et al.31
described a comprehensive system to
classify acute muscle injuries based on
the severity of imaging assessments
using MRI or ultrasound and the
exact anatomical site (including the
proximal or distal tendon, proximal
or distal musculo-tendinous junction
and muscular injuries). The British
Athletics Muscle Injury Classification28
grades muscle injuries from 0-4,
based on MRI parameters of the
extent of injury and classifies the
injuries according to their anatomical
site within the muscle (Table 5). In
total, the classification constitutes
11 grading categories combining the
severity grading and the anatomical
site classification. There is evidence
in hamstring and soleus muscle
injuries that those injuries which
involve the tendon are associated with
longer time to RTP32–36 which would
CHAPTER 2
be expected by an understanding
of tendon healing and adaptation
to load. The British Athletics Muscle
Injury Classification has been assessed
for reliability in two radiological
studies,37,38 and shown associations
with RTP in one retrospective
clinical review,33 but further work is
required to investigate its prognostic
significance and relevance among
football players. The Munich consensus
statement classification system39 was
developed for muscle injuries in 2012,
differentiating between functional
muscle disorders and structural muscle
injury (Table 4). It has shown a positive
prognostic validity among professional
football players in a correlation study.40
However, the differentiation between
‘functional’ and ‘structural’ has been
criticized.28,41
A strength with using more detailed
classification systems including
grading and severity, is that they
force a more accurate description
of the injury with a more diagnostic
precision and defined tissue
involvement, which may aid clinicians
when communicating with other
professionals, athletes or coaches.
However, more comprehensive
classification systems may
compromise on the ability to provide
an accurate prognosis. One of the
problems is that there are large
individual variations in time RTP
within each of the categories,42 and
the evidence here is scarce. The most
important may be that clinicians specify
which classification or grading system
they are using to avoid misinterpretation
and/or miscommunication in clinical
practice and research.
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
GRADE CLINICAL EXAMINATION
O’Donoghue (1962)43
0 Lack of any ultrasonic lesion
I No appreciable tissue
tearing, no loss of function
or strength, only a low-grade
inflammatory response
II Tissue damage, strength,
only a low-grade
inflammatory response
III Complete tear of
musculotendinous unit,
complete loss of function
CHAPTER 2
Järvinen (2005)10
Mild (first-degree): strain/
contusion represents a tear
of only a few muscle fibers
with minor swelling and
discomfort accompanied by
no or only minimal loss of
strength and restriction of the
movements
Moderate (second-degree):
strain/contusion with greater
damage of the muscle with a
clear loss in function (ability
to contract)
Severe (third-degree)
strain/contusion: tear
extending across the entire
cross section of the muscle,
resulting in a virtually
complete loss of muscle
function is termed.
<
ULTRASONOGRAPHY MRI Table 3
19
Overview of
Peetrons (2002)22 Modified Peetrons simple clinical and
Ekstrand et al. (2012)23 radiological grading
systems for muscle
Negative MRI without any injuries
visible pathology
Minimal elongations with Oedema but no architectural
less than 5% of muscle distortion
involved. These lesions can
be quite long in the muscle
axis being usually very
small on cross-sectional
diameter (from 2 mm to 1 cm
maximum)
Partial muscle uptures; Architectural disruption
lesions involving from 5 to indicating partial muscle tear
50% of the muscle volume or
cross-sectionaldiameter. The
patient often experiences a
“snap” followed by a sudden
onset of localized pain.
Hypo-and/or anechoic gap
within the muscle fibers
Muscle tears with complete Total muscle or tendon
retraction. rupture.
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20 MUNICH CONSENSUS STATEMENT: CLASSIFICATION OF ACUTE MUSCLE DISORDERS AND INJURIES

<
INDIRECT MUSCLE DISORDER/INJURY: DIRECT MUSCLE INJURY: Table 4
The Munich
FUNCTIONAL MUSCLE DISORDER consensus statement
classification of acute
Type 1 Overexertion-related muscle disorder Contusion muscle disorders and
injuries39
Type 1A: Fatigue-induced muscle disorder

Type 1B: Delayed-onset muscle soreness (DOMS)

Type 2 Neuromuscular muscle disorder

Type 2A: Spine-related neuromuscular Muscle disorder

Type 2B: Muscle-related neuromuscular Muscle disorder

STRUCTURAL MUSCLE INJURY Laceration

Type 3 Partial muscle tear

Type 3A: Minor partial muscle tear

Type 3B: Moderate partial muscle tear

Type 4 (Sub)total tear Subtotal or complete muscle tear

Tendinous avulsion

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

BRITISH ATHLETICS MUSCLE INJURY CLASSIFICATION 21

<
GRADING ANATOMICAL SITE COMBINED CLASSIFICATION Table 5
The British Athletics
Grade 0: a. Myofascial 0a: MRI normal Muscle Injury
Negative MRI Classification28
b. Musculotendinous 0b: MRI normal or patchy HSC throughout one or more muscles.
Grade 1:
c. Intratendinous 1a: HSC evident at the fascial border <10% extension into muscle belly. HSC of CC length <5 cm.
“Small injuries
(tears) to 1b: HSC <10% of CSA of muscle the MTJ. HSC of CC length <5 cm (may note fibre disruption of <1
the muscle” cm).
Grade 2: 2a: HSC evident at fascial border with extension into the muscle. HSC CSA of between 10%-50% at
“Moderate maximal site. HSC of CC length >5 and <15 cm. Architectural fibre disruption usually noted <5 cm.
injuries (tear)
2b: HSC evident at the MTJ. HSC CSA of between 10%-50% at maximal site. HSC of CC length >5
to the muscle”
and <15 cm. Architectural fibre disruption usually noted <5 cm.
Grade 3:
2c: HSC extends into the tendon with longitudinal length of tendon involvement <5 cm. CSA of
“Extensive tears
tendon involvement <50% of maximal tendon CSA. No loss of tension or discontinuity within the
to the muscle”
tendon.
Grade 4:
3a: HSC evident at fascial border with extension into the muscle. HSC CSA of >50% at maximal site.
“Complete
HSC of CC length of >15 cm. Architectural fibre disruption usually noted >5 cm
tears to either
the muscle or 3b: HSC CSA >50% at maximal site. HSC of CC length >15 cm. Architectural fibre disruption usually
tendon” noted >5 cm
3c: HSC extends into the tendon. Longitudinal length of tendon involvement >5 cm. CSA of
tendon involvement >50% of maximal tendon CSA. May be loss of tendon tension, although no
discontinuity is evident
4: Complete discontinuity of the muscle with retraction
4c: Complete discontinuity of the tendon with retraction

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<
22 GRADE ACTIVE KNEE GAIT TYPICAL Table 6
FLEXION (°) PATTERN PRESENTATION Classification of
Quadriceps contusion.
MILD <90° Normal May or may not remember incident Adapted from Jackson
(Grade I) & Feagin (1973), in
Can usually continue activity
Kary et al. (2010)7
Sore after cooling down or next morning and Brukner & Kahn
Minimal pain w/resisted knee straightening (2017)12

Might be tender with palpation

Full prone ROM
+/- Effusion
+/- Increased thigh circumference

Moderate 45-90° Antalgic Usually remembers incident, but can continue activity, although may stiffen up
(Grade II) (slight limp) with rest (half-time or full-time)
Mild/moderate swelling
Pain w/palpation
Pain w/resisted knee straightening
Limited ROM
+/- Effusion
+/- Increased thigh circumference

Severe >45° Severe limp Usually remembers incident. Assisted ambulation, difficulty with full weight-bearing
(Grade III)
Severe pain
Immediate swelling/bleeding
Pain with static contraction
+/- Bulge in the muscle
+/- Increased thigh circumference

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MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

THE FC BARCELONA MUSCLE INJURY CLASSIFICATION – A PROPOSAL

The FC Barcelona muscle injury classification proposal44 is an evidence-informed and expert consensus-
based classification system for muscle injuries developed by experts from three institutions (FC Barcelona
Medical Department, Aspetar, and Duke Sports Science Institute); it is based on a four-letter initialism system:
MLG-R, respectively referring to the mechanism of injury (M), location of injury (L), grading of severity (G),
and number of muscle re-injuries (R) (see Table 7).

<
MECHANISM OF INJURY (M) LOCATIONS OF INJURY (L) GRADING OF NO. OF MUSCLE Table 7
SEVERITY (G) RE-INJURIES (R) Summary of the
proposed FC
Hamstring direct injuries P Injury located in the proximal third of the muscle belly 0–3 0: 1st episode Barcelona muscle
T (direct) classification system44
M Injury located in the middle third of the muscle belly 1: 1st reinjury
D Injury located in the distal third of the muscle belly 2: 2nd reinjury...

Hamstring indirect injuries
I (indirect) plus sub-index s
for stretching type, or sub-
index p for sprinting type
P Injury located in the proximal third of the muscle belly. 0–3 0: 1st episode
The second letter is a sub-index p or d to describe the
1: 1st reinjury
injury relation with the proximal or distal MTJ, respectively
2: 2nd reinjury...
M Injury located in the middle third of the muscle belly,
plus the corresponding sub-index
D Injury located in the distal third of the muscle belly, plus
the corresponding sub-index

Negative MRI injuries (location N p Proximal third injury 0–3 0: 1st episode
is pain related) N plus sub-
23
N m Middle third injury 1: 1st reinjury
index s for indirect injuries
stretching type, or sub-index p N d Distal third injury 2: 2nd reinjury…
for sprinting type

Grading of injury severity

0: When codifying indirect injuries with clinical suspicion but negative MRI, a grade 0 injury is codified. In these cases, the second letter
describes the pain locations in the muscle belly
1: Hyperintense muscle fiber edema without intramuscular hemorrhage or architectural distortion (fiber architecture and pennation
angle preserved). Edema pattern: interstitial hyperintensity with feathery distribution on FSPD or T2 FSE? STIR images
2: Hyperintense muscle fiber and/or peritendon edema with minor muscle fiber architectural distortion (fiber blurring and/or pennation
angle distortion) ± minor intermuscular hemorrhage, but no quantifiable gap between fibers. Edema pattern, same as for grade 1
3: Any quantifiable gap between fibers in craniocaudal or axial planes. Hyperintense focal defect with partial retraction of muscle fibers ±
intermuscular hemorrhage. The gap between fibers at the injury’s maximal area in an axial plane of the affected muscle belly should be
documented. The exact % CSA should be documented as a sub-index to the grade
r: When codifying an intra-tendon injury or an injury affecting the MTJ or intramuscular tendon showing disruption/retraction or loss of
tension exist (gap), a superscript (r) should be added to the grade

THE BARÇA WAY: CLASSIFYING MUSCLE INJURIES

The FCB muscle injuries proposal has several key points; the starting point was to incorporate
the scientific evidence about muscle injuries at this time within the proposal, the classification
was built up within this idea, together with the medical experience of the three sports medicine
institutions involved in the project. It is also very important that the structure of the proposal is
flexible; the proposal has the capability to adapt to future scientific evidence within the muscle
injury field and grow with the future knowledge.

The role and function of connective tissue in force generation and transmission is in our opinion
a key factor in the signs, symptoms and prognosis of muscle injuries. Thus, it was one of our
purposes to create a grading item that could classify injuries based on a quantifiable parameter
(exact % CSA) based on the principle that the more connective tissue is damaged, the greater the
functional impairment and the worse the prognosis of the injury will be. The history of an injury
plays also an important role, it will not be the same to face a first injury episode than a re-injury or
a second reinjury, so the chronology of the injury is included in our proposal.

The purpose is to avoid confusing terminology will help to have and easy communication. The
classification is still a theoretical model that needs to be tested and see if it shows an adequate
grouping of injuries with similar functional impairment, and prognostic value. The goal of the clas-
sification is to enhance communication between healthcare and sports-related professionals and
facilitate rehabilitation and RTP decision-making.

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PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
2.3.1
EXERCISE PRESCRIPTION
FOR MUSCLE INJURY
When a player sustains a muscle injury, the chances of it recurring are high. In
fact, epidemiological research consistently identifies previous injury as the most
powerful risk factor for muscle injuries.1 Fortunately, the risk of recurrence can
be reduced through careful management of the return to play process, including
appropriate prescription of therapeutic and football-specific exercises.
— With Phil Glasgow, Thor Einar Andersen and Ben Clarsen
24 A carefully planned exercise
programme is not only essential to
optimise the quality of healing tissues,
but also to maintain the player’s fitness,
skills and football cognition so that
when they do return to play, they are
ready to perform optimally.
This chapter outlines the general
principles of exercise prescription for
muscle injuries, including strategies
to optimise structural adaptations
and maintain football-specific fitness,
skills and cognition. The chapter is not
intended as a recipe; practitioners need
to consider each player individually and
assess their progress throughout the
entire RTP process.
BEGIN WITH THE END
IN MIND
In top-level football, the medical
and performance team is under
constant pressure to return the player
to competition safely, in the shortest
possible time. To accomplish this, they
need to manipulate a range of training
variables to ensure that the player is
working at the limit of their capacity,
while simultaneously allowing sufficient
time and restitution for tissue healing. To
define the necessary tissue capacity and
functional requirements, practitioners
need a detailed understanding of the
football-specific activities and level to
which the player must return. We refer to
this as beginning with the end in mind.
At FC Barcelona, this involves a close
collaboration between the player and
medical, coaching and performance
analysis specialists.
CHAPTER 2
STRUCTURED, BUT
FLEXIBLE
The RTP process is a dynamic continuum
during which the nature and difficulty of
exercises are progressed in response to
tissue healing and the functional abilities
of the player. Every player is unique, and
no two injuries are exactly the same.
As such, the RTP process should be
individualised. The multi-dimensional
nature of return to play means that the
therapists, strength and conditioning
and technical staff must organize several
concurrent phases with different goals
and milestones.
FACTORS INFLUENCING LOADING
PROGRESSION
The most common way of measuring
progress in the RTP process is the player’s
perception of pain.2 The amount of
discomfort tolerated during training should
be guided by the rationale for the specific
exercise. For example, when the primary
goal of the exercise is tissue loading, some
discomfort may be acceptable. In contrast,
when the focus is to restore movement
quality, exercises should be pain-free.
Other tests of muscle function (e.g. Askling’s
H-test and Isokinetic testing) can also
help inform RTP readiness. However, it
is important to recognise that no single
test can determine the player’s ability to
progress. Instead, practitioners should
use a battery of tests assessing different
aspects of function. Execution of sport
specific skills with good technique also
helps guide progression. Clinical testing
for specific muscle groups is discussed
in the relevant sections. It is necessary
to communicate closely with the player
throughout return to play process to ensure
the programme aligns with their functional
ability, psychological readiness and specific
performance demands.
TARGET SPECIFIC
ADAPTATIONS
When designing an exercise programme,
practitioners should ask a number of
simple questions (Figure 1):
• What is happening at a tissue level?
• What outcomes are you trying
to achieve with your exercise
prescription?
• What is the specific adaptation
associated with different exercise or
football activity types?
• Is the goal of the exercise to
reduce symptoms, stimulate tissue
adaptation (tissue capacity) or
enhance function (movement
capability)?
Once the desired outcome of an exercise
or football activity is clear, it is possible to
plan progressions to maximise adaptation.
For example, where the goal of loading is
increased fascicle length, the intervention
may be eccentric loading and progression
will include addition of load, increased
speed and range of motion. In contrast,
where the desired outcome is to increase
rate of force development, the exercise (or
football activity) may be a jump squat and
progressions involve a move from high
load power (80% 1RM load) to low load
power (30% 1RM load).
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

< 25
Loading Strategy: Figure 1
Analgesia What Are the Goals of
Loading? MUR = Motor
MUR Unit Recruitment,
Loading Strategy:
RFD= Rate of Force
Kinetic chain Loading Strategy: Development
Tension in system MTU Morphology
Proximodistal sequencing Stiffness
RFD Fascide lengh
Sport-specific skills PAIN Collagen reorganisation

MOVEMENT TISSUE
CAPABILITY CAPACITY
(FUNCTION) (TISSUE)

TARGET SPECIFIC RESTORING MUSCLE STRUCTURE STRENGTH TRAINING

ADAPTATIONS
The RTP process commences almost
immediately following injury with
attention given to graduated loading of
the injured tissue to facilitate healing.
While the main focus of management
during the early stages of the RTP process
will be directed towards resolving the
clinical signs and symptoms, targeted
loading of the tissue should also be
included. Early loading is an effective
stimulus for regeneration and has been
shown to result in better outcomes
in terms of capillary ingrowth, less
fat infiltration, fibre regeneration,
more parallel orientation of fibres,
less intramuscular connective tissue,
improved biomechanical strength and
less atrophy.3
Muscle tissue is highly sensitive and
adaptable to mechanical loading.
Following injury, muscle undergoes a
number of changes in structure and
function both as a direct consequence
of tissue insult and as an indirect
consequence of reduced loading
and recruitment. These changes
include, reduced fascicle length and
physiological cross-sectional area (PSCA)
as well as alterations in neuromuscular
activation.4-7 The RTP process should
therefore focus on restoring muscle
structure (especially fascicle length and
cross-sectional area).
Adequate strength is essential for safe
and effective return to football. During the
return to play process, strength training
should concentrate on the restoration of
injury-related deficits. Lieber8 has suggested
that during the first two weeks of strength
training in uninjured, untrained individuals,
only 20% of strength increases may be
attributed to structural changes. This implies
that initial strength gains are primarily due
to neuromuscular adaptations. Given that
following injury neuromuscular capacity can
be significantly diminished, it is reasonable
to suggest that it may be more effective
during the early stages of return to play
to carry out strengthening exercises ‘little
and often’ in order to avoid neural system
fatigue and facilitate both structural and
neuromuscular adaptations.

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26 EARLY IN THE RTP PROCESS:
MOVEMENT IS KEY
Simple isotonic training may be necessary
to facilitate motor recruitment in the early
stages of the RTP process. The recruitment
of muscles throughout range during
functional movements often help to restore
pain free range of motion and normalise
pain. While there is some evidence that
isometric contractions may reduce pain in
tendinopathy, more dynamic movements
tend to be more effective in muscle injury
management. Some principles for early
strengthening of muscle following injury
are summarised below.
As soon as the player can effectively
recruit the muscle without significant
pain or inhibition, it is important to
incorporate eccentric (lengthening)
contractions. Eccentric contractions have
consistently been shown to result in
greater morphological and neuromuscular
adaptations than both isometric and
concentric training.9,4,5
ECCENTRIC EXERCISE IN RTP PROCESS:
WHEN AND HOW?
Eccentric exercise has become the mainstay
of the muscle injury return to play process.
Traditionally, clinicians often delay the
introduction of eccentric training until late
stage rehabilitation due to perceived risks
associated with increased muscle tension
and associated muscle soreness. This is
also reflected in most RCTs, where eccentric
training is often not included until halfway
through the RTP process. However, two
protocols have included eccentric training
from day 5 onwards, and both reported
favorable outcomes in terms of RTP time
and recurrence rates.10-12 Importantly, neither
study reported adverse effects with the
early inclusion on eccentric training.
Although protection of the injured muscle
is paramount, low-level, controlled
eccentric exercises have the potential to
further reduce pain inhibition and facilitate
tissue adaptation without causing any
further damage. Practitioners must take
care to ensure that the player can tolerate
the resistance, complexity and range of
motion. They should seek to identify ways
to stimulate the muscle under lengthening
conditions while providing appropriate
support and safety. Examples of early
stage eccentric training are included in
the relevant muscle specific sections and
football specific exercises below.
Eccentric training should be maintained
throughout the entire RTP process
and should target movement-specific
adaptations for the affected muscle. For
example, for hamstring training should
include both knee-flexion dominant and
hip-extension dominant movements.
Similarly, for quadriceps injury, eccentric
exercises should focus on both hip flexion
and knee extension. Examples are included
in the muscle specific sections.
RESTORING FOOTBALL-
SPECIFIC FITNESS,
SKILLS AND COGNITION
Muscle injuries have a range of
consequences on a player’s football
performance that need to be addressed
throughout the RTP process. Therefore,
you have to think wider than just the
injured muscle.
At the injury site, the injured muscle and
its agonists will lose strength, power, and
endurance capacity. The extent to which
each of these attributes is affected should
be identified using specific testing, for
example isokinetic and jumping tests.
Thereafter, exercise prescription should
specifically address the identified deficits.
Muscle injury results in both structural and
neuromuscular deficits. During football
sporting activities, muscle is constantly
‘tuned’ to enable an individual to maintain
position, move voluntarily and react to
perturbations.13 Neuromuscular control
(NMC) is the product of the complex
integration of afferent proprioceptive input,
central nervous system (CNS) processing
and neuromuscular activation. While great
attention has been given to the role of NMC
in ligament rehabilitation, it has often been
overlooked in muscles.
There is evidence that prolonged deficits
in NMC following muscle injury may have
a role to play in recurrence. Reduced
activation of previously injured biceps
femoris long head at longer muscle lengths
may be related to shorter fascicles, eccentric
weakness and reduced ability to protect the
muscle at longer lengths.14,15 Reduction in
the ability of the muscle produce, transfer
or modulate load will likely result in an
increased risk of reinjury. The RTP process
should therefore seek to improve the central
nervous system’s ability to fine tune muscle
coordination and improve the football skill
execution; this is discussed below.
It is important when designing strength
training programmes that the content
reflects how the muscle functions during
football. Careful manipulation of training
load, volume and frequency can achieve

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
football-specific performance benefits such
as increased muscular endurance, running
speed or jump height, as well as protection
from recurrence.
Muscle injuries also have consequences on
the player’s general conditioning, including
their cardiovascular fitness and their
general load tolerance. A comprehensive
RTP programme must therefore include
general conditioning strategies that
replicate the player’s normal football
demands as much as possible, both in
terms of the metabolic pathways involved,
and the stresses on musculoskeletal
system.
An intelligently designed return to
play programme that has the correct
combination of contraction type (concentric,
eccentric, isometric, plyometric), exercise
choice (e.g. free weights vs. machine
weights and football activities), load,
number of sets, repetitions, speed of
contraction and frequency of training
can significantly enhance the benefits
of training. Principles for progression of
strengthening during the mid to late stage
of the RTP process include: Max Strength
> Longer Muscle Lengths > Rate of Force
Development Training > Move from
Moderate to High Speed with and without
ball and on and off field. Hence, the nature
of training used should minimise stress on
the injured tissues while simultaneously
exercising muscle groups involved in
football. This is essential towards the end
of the RTP process to adapt to the high
demands of match play. The footballer must
have trained enough and specific to return
to football and performance safely.16
It is widely accepted that the ability to move
part or parts of the body through a wide
CHAPTER 2
range of purposeful movements during
a sporting event can have a significant
influence on football performance and the
potential for (re)injury. It is also recognized
that that functional ranges of motion during
activities such as kicking and long passes
exceed those normally measured during
clinical assessment.17 The role of flexibility
in the site of muscle injury has been the
source of debate for many years with
conflicting findings for all major muscle
groups.
Tests of multi-segmental whole body
mobility18 and dynamic flexibility17 have
shown strong correlations with injury
presentation and may be more useful
measures (and interventions) of flexibility
during the RTP process. It is suggested
that mobility training during the RTP
process reflects the range and direction
of the movements carried out during the
football activities. Rather than a reductionist
approach that views flexibility in isolation,
clinicians should consider whether a
muscle group has adequate flexibility
combined with increased strength at longer
lengths for safe and effective function.
MAINTAINING FOOTBALL COGNITION
As the RTP process develops, the complexity
of the task should be increased to involve
multiple segments through multiple planes
of movement. Early examples of this include
football -specific tasks such as dribbling,
passing and receiving a ball, snake runs
and basic training drills. Particular attention
should be given to facilitating effective
loading of tissues through functional
patterns as well as release and attenuation
of force; for example, deceleration and
change of direction.
Introduction of unanticipated 27
movements is essential for effective
restoration of function. The ability to
respond to a dynamic and variable
environment is often a key driver in the
perpetuation of symptoms. Gradual
introduction of physical perturbations
facilitates reactive neuromuscular
adaptations as well as sudden responses
to verbal or visual commands. At all
times the quality of the movement is
monitored and where maladaptive
patterns are adopted, exercises and
football activities should be regressed to
ensure correct form.
Reintroduction of sport-specific skills,
competition and other environmental
constraints should focus on widening the
movement repertoire of the athlete and
allow sufficient time for skill acquisition
and consolidation through practice. It
is important to incorporate cognitive
challenges and decision making into the
rehabilitation programme.
At FC Barcelona, every effort is made
to return the injured player to modified
training participation on the pitch and
with the team as early as possible to
preserve football technical and tactical
skills and cognition abilities. As much as
possible should be done with a ball as
soon as possible and drills should reflect
the demands of the player, such as team
tactics, position and role in the team.
Data derived from Global Positioning
Satellite (GPS) systems during training
drills and match play is used to tailor the
on-field RTP process individually in close
collaboration between medical staff,
performance analysts and coaching staff.
Specific examples are discussed in the
next section.
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

INJURY Acute stage

Targeted treatment

Restoring gym - based activities

Basic field workout

Complex field workout

<
Figure 2
The FC Barcelona

RETURN TO TRAINING RETURN TO PLAY ‘Return to Play

Process’

28
THE BARÇA WAY:

The above schematic (figure 2) provides an overview of the Return to

Play process in FC Barcelona in regards to managing and rehabilitating
the injured player. The various components are not step by step i.e. you
do not need to complete one before moving to the next; this process is
dynamic and components can overlap as the player progresses throu-
gh the RTP process.

The key point is to get the player moving as soon as is safely possible.
1. The acute stage following the injury can last anywhere from
approximately 1 to 3 days. At this very early stage, the focus is on
ice and compression.

2. Table treatment is the time to stimulate the muscle and promote

healing and gain mobility – e.g. passive and active muscle stret-
ching, isometric and eccentric types of contractions.

3. As soon as possible, it is time to get the player moving in the gym.

This component can be (and usually is) a combination of table
treatment and gym based exercises, from basic through to more
advanced functional exercises (as the progression of the injured
player allows). The key is to progress continuously from passive
workouts to active workouts.

4. Basic field work – In this component of the RTP process, we start

to introduce field based sessions, with varying surfaces. It is
important to maintain the gym work here, but to reduce the table
treatment. Basic football skills are reintroduced and trained and
position specific movements are included.

5. Complex field work – In this part of the RTP process, the basic
work in the field is phased out in favour of more advanced skills
and movements with decision-making tasks at higher intensities
and more challenging. Gym work is still maintained here, in parti-
cular as a pre field session activation.

6. As the player has sufficiently progressed through this RTP process,

he/she is ready to return to training, starting partial training with
the team (maintaining additional work with the physical coaches).
With appropriate management of loads, the players demands will
be increased until he/she is ready to join 100% with the team.

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PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
2.3.2
RESTORING PLAYERS’ SPECIFIC
FITNESS AND PERFORMANCE
CAPACITY IN RELATION TO MATCH
PHYSICAL AND TECHNICAL
DEMANDS
Restoring the players’ specific fitness and performance capacity before joining the
team for collective training sessions and competitions is essential
— With Martin Buchheit and Nicolas Mayer
In the lead up to returning to
unrestricted football training and play,
the players generally train individually
with a physical/rehabilitation coach
who ensures that the player’s
locomotor (i.e. running/movement)
and technical loads are progressively
built in relation to match demands
(figure 1), while respecting indices
of load tolerance, well-being (i.e.
how the player is coping with those
loads) and psychological readiness.
Importantly, since these individual RTP
sessions should prepare the players to
train/play with the team within a few
days, it is of utmost importance for
the ball to be integrated as much as
possible, and that specific movement
coordination and muscle actions,
decision-making, mental fatigue and
overall self-confidence are considered
continuously.
To illustrate our approach, we provide
example of sequential RTP load
progressions, i.e., designed for two
common muscle injuries (hamstrings
and rectus femoris) for two different
playing positions in the field (wide
defender, WD full back - FB and central
midfielder (playing as a ‘6’), CM)
(figure 2). The re-conditioning of both
muscle groups requires the targeting
of different locomotor patterns (with
reference to the selective activation of
those muscles in relation to specific
running phases1); playing positions
are also associated with distinct
locomotor and technical demands
(figure 1), which all need to be taken
into account when designing the RTP
program. While we acknowledge
that there exist large differences in
locomotor and technical demands
CHAPTER 2
within the same positions due to 29
variations in players’ physical profiles,
style of play and match context,
we have chosen to use the average
demands of those 2 playing positions
as a starting point to illustrate our
methodology. In real-life scenarios,
we recommend the systematic use of
each player’s unique locomotor and
technical profile based on historical
club data (i.e. from match analysis
data) and personal observations (style
of play and technical demands).
MATCH DEMANDS
The physical activity performed during However, we use this to illustrate the
matches should be considered as target for importance of the distinction between
the conditioning programming. Assuming HSR and HIA in relation to individualising
that the building up of minutes of play the RTP program according to the muscle
during matches may be progressive as injury location and player demands.
well following an injury (i.e., playing 25-35
min as a sub for the first match post injury),
the demands of 1 full half (45 min) to 60
minutes could be considered as the initial
pre-competition target. To assess those
specific physical demands, we recommend
assessing the injured player’s locomotor
load with respect two distinct types of
demands; high-speed running (HSR, which
essentially put constrains on the hamstring
muscles) and high-intensity actions (HIA)
which encompasses all acceleration,
deceleration and changes of direction
activities and put major constrains on
the quadriceps, adductors and the gluts)
(figure 1). In the example given, we use
mechanical work (MW) as the metric
to measure HIA. It is important to note
that this metric currently has preliminary
validity and reliability only and needs to be
tested further in scientific investigations.
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

Locomotor volume Locomotor intensity

HSR (m) MW (A.U) HSR - WD HSR - CM MV - WD HSR - CM
1000 80

1st half
30 900
70
90 3,0

800 80 MW
60
#2/4 2,5
700 70
HSR
Mechanical Work (A.U)

50 #2/4
600 60 2,0

MW (A.U) / min)
GS
HSR (m) / min
HSR (m)

500 40 50 #4
1,5
400 40
30

300 30 1,0
PO
20 #2
200 20
MW 0,5
10 #6 HSR
100 10 #6
PO
#2
0 0 0 0,0
WD CM 0 2 4 6 8 10 12 14 16

Work period duration (min)

^
Figure 1
Summary of the worst case-scenarios for locomotor volume demands (± standard deviation, SD) during League 1 and Champions League matches (1st half) for a wide
defender (WD) and a midfielder (playing as a ‘6’, CM), in terms of volume (left panel) and intensity (right panel) of high-speed running (HSR) and HIA expressed as
mechanical work (MW). Volume refers to the greatest running distances covered during halves (± SD). Intensity is expressed, over exercise periods from 1 to 15 min, as 1)
peak distance ran > 19.8 km/h per min, which is used as a proxy of HSR intensity and 2) peak MW per min (adapted from2). For example, over block periods of 4 min, CM
can cover a maximum of 20 m of HSR / min. Similarly, WD can cover up to 55 m of HSR over 1 min-periods. For figure clarity, SD (̃25%) are not provided for peak intensities.
Adapted from Lacome et al.3 The blue and red circles refer to the different specific training drills within S4 sessions, as indicated in Table 1 (HSR) and 2 (WM) with orange and
blue backgrounds, respectively. #2/4 refers to the types of high-intensity training sequences with both a high neuromuscular strain and a metabolic component (mainly
oxidative energy, Types #2; oxidative and anaerobic energy contribution, Type #4). #6 refers to Type #6 drills involving a high neuromuscular strain (but a low metabolic
component), referring to quality high-speed and mechanical work training (long rests in between reps). The HSR and mechanical work intensity of 4v4 game simulations
(with goal keeper, GS) and 6v6, 8v8 and 10v10 possession games (PO, without goal keeper) in which player participate at the end of the RTP process (S5, Table 1 and 2) is
also shown. HSR intensity is not mentioned for such GSs, since the size of the pitch prevents player to reach such high speeds.

MUSCLE INJURED, It is essential to build the cognitive and change of direction (i.e. measured MW
LOAD PROGRESSION technical aspects alongside the locomotor
demands. The sessions detailed in Figure
as a proxy of HIA), speed and strength
training which primarily relies on the
AND INTEGRATION 2 and table 1 are designed to target, performance of the neuromuscular
OF POSITION-BASED alongside the integration of player-
and position-specific technical tasks
system. Metabolic conditioning refers
to the contribution and development
PHYSICAL AND i) neuromuscular components in an of the aerobic and/or anaerobic energy
TECHNICAL MATCH isolated manner (“quality” sessions, such
as Type #6 4, see Table 1 legend) as well
systems.4 It is important to consider
that the progressions in load should be
DEMANDS as ii) metabolic conditioning that often subtle to avoid excessive spikes.5 We
also integrates important neuromuscular believe that the progressions should
demands (such as Types #2 or #44 see also be aimed at building up locomotor
table 1 legend). Neuromuscular training loads with alternations in session main
refers to acceleration, deceleration, objectives (cf tactical periodization

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

31
paradigm, allowing the physiological quality targeted
a given day to recover the following day6). This should
avoid creating excessive muscle soreness / residual
fatigue from one day to the other, and helps players
to train every day, which in turn may accelerate their
full return to train/competition. Figure 2 illustrates
how the locomotor contents of the sessions, in terms
of HSR and MW may be modulated in response to
1) the muscle injured and 2) the position-specific
locomotor demands. Table 1 and 2 provide the details
of the sessions both in terms of locomotor load and
technical orientations. For example, after a typical
introductory session (S1) the focus/building up of
HSR vs. MW differs in relation to muscle injury [with a
greater emphasis on progressively building HSR after
hamstring (HS) injury (S2HS) vs. building MW after
a quadriceps injury (S2Q)]. After some progressions
in terms of HSR and MW, the locomotor targets are
further adapted based on the player’s playing position.
Following those final individual sessions (S1-S4),
when it comes to transitioning with the team, we
request players to participate in some (but not all)
team training sequences, and to perform some extra/
individualized conditioning work. When taking part to
in some of the game situations, we have them playing
as jokers (or floaters, being systematically with the
team in possession of the ball) for a few days, which
has been shown to decrease their locomotor demands
by 30% compared with the other players.2 This offers a
relatively safe (less contacts, no defensive role and no
shots) and progressive loading for RTP players, while
allowing them to be exposed to the most specific
types of locomotor (especially decelerations and
turns), technical and cognitive demands. This last
phase of the RTP process is crucial since it allows
players to regain their confidence and in turn, their
full match-performance capacity. Finally, before their
participation with the team as jokers/floaters, RTP
players need sometimes to be exposed to specific
warm-up sequences. They should also perform
some individual conditioning work post session (in
relation to the injury and individual game demands)
(table 1 and 2).

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 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

32

^
Figure 2
Example of four sequential RTP load progressions
in terms of the volume of locomotor demands,
i.e., high-speed running (HSR) and mechanical
work (MW). The sessions are designed for two very
common muscle injuries (i.e., hamstrings, see details
in Table 1 and rectus femoris, see details in Table 2)
for two different playing positions in the field (wide
defender, WD and central midfielder, MD). The size of
the battery represents the actual/absolute volume of
match demands (one half), while the coloured part
within each battery represents the relative portion
of one-half demands that is completed during the
given session. Note that the total number of sessions
required within each phase is obviously injury and
context-dependent.

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

< 33
S1: Introduction session
Table 1
• Low-intensity running related to sensations (6-8’) Example of session
details of the
• Hip mobility + Running drills
hamstring injury
• Agility closed-drills sequential RTP load
progressions.
• Functional work (without the ball)
• Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
• Cool down (3-5’)

S2HS:
• Monitoring (1): 4-min run at 12 km/h
• HIP mobility + Running drills
• Agility closed-skills (quality)
• Functional work with the ball (preparation)
• Technical Work with a Metabolic component
• Type #1: 1 x 3-min set: 15s (slalom run 65m) /15s (jog) (> 19.8
km/h ≈ 250m, MaxV < 22 km/h)
• Cool down (3-5’)
S3HS:
• Hip mobility + Running drills
• Agility closed to open-skills + Technical work
• Monitoring (2): 4 straight-line high-speed runs(box-to-
box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
200m)
• Technical Work Metabolic component + Neuromuscular
constraints
• Type #2: 1 x 6min 40s set: 10s (50 m) /20s (passive) + 5s
(28 m) /15s (passive) (> 19.8 km/h ≈ 250m, MaxV < 24
km/h)
• Cool down (3-5’)

S4HS-WD:
• Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality)
• Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV
> 25km/h, rest between reps: 45s)
• Technical work: being orientated (3/4), dribbling and
crossing
• I. Type #2: 1 x 4-min set: 10s (slalom 55 m) /20s (passive)
(>19.8km/h ≈ 400m) *
• II. Type #2: Specific WD: 1 x 4-min set: 10s (technical
demand: dribbling, passing, crossing) / 20s (passive)
(>19.8km/h ≈ 300m)
S4HS-CM:
• Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality)
• Type #6: Speed progression: 1x 10m, 1x 15m, 1x 20m (MaxV
> 25km/h, rest between reps: 45s)
• Technical work: taking information, controlling and COD
with the ball, passing (5 to 20m)
• I. Type #2: 1x 4-min set: 10s (COD = 2x 25m)/ 20s (passive)
+ 5s (constraints)/25s (passive) (>19.8km/h ≈ 200m)
• II. Type #2: Specific CM: 1x 4-min set: 10s (with technical
demand: turning, dribbling, passing) / 20s (passive)
(>19.8km/h ≈ 150m)

S5hs-WD and S5hs-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal
keepers) with the team as jokers/floaters initially, we recommend players to do some extra Type #6 high-speed runs aiming at reaching
close-to-max velocities (with the volume adjusted with respect to distance of the following match). S4HS-WD drills with an orange
background refer to the drills shown in Figure 1, right panel.

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
34
Distance to run are provided for a
player with an average locomotor
profile (i.e., maximal aerobic speed 17.5
km/h, velocity reached at the end of the
30-15 Intermittent Fitness test (VIFT7) of
20 km/h and maximal spring speed of
32 km/h8). Note that the physiological
objectives of each locomotor sequence
(in terms of metabolism involved and
neuromuscular load) is shown while
using one of the 6 high-intensity
training Types as suggested by
Buchheit & Laursen.4 Type #1, aerobic
metabolic, with large demands placed
on the oxygen (O2) transport and
utilization systems (cardiopulmonary
system and oxidative muscle fibers);
Type #2, metabolic as type #1 but with
a greater degree of neuromuscular
strain; Type #3, metabolic as type #1
with a large anaerobic glycolytic energy
contribution but limited neuromuscular
strain; Type #4, metabolic as type #3
but a high neuromuscular strain; Type
#5, a session with limited aerobic
CHAPTER 2
response but with a large anaerobic See Table 1 for
legends. Note: for the
glycolytic energy contribution and S2Q session, 10s/10s
high neuromuscular strain; and Type is preferred to other
#6 (not considered as HIIT) involving HIIT formats for the
fact that it requires
a high neuromuscular strain only, a greater number
referring typically to quality high-speed of accelerations
and mechanical work training (long than with longer
intervals, which
rests in between reps). Extended from may help building
figure 1 in Buchheit & Laursen.4 Red up this capacity in a
controlled and safe
font: emphasis on HSR running. Blue manner.
font: emphasis on MW. Green font:
monitoring drills (see below). Text
highlighted in orange refers to the HSR
drills shown in figure 1 (right panel);
Text highlighted in blue refers to the
MW drills shown in figure 1 (right
panel). Note: Slalom runs with 45°
angles are often used (e.g., S1, S2HS)
to decrease the actual neuromuscular
load: turning at 45° requires to
decrease running speed (less HSR) and
doesn’t requires to apply strong lateral
forces (less MW), which in overall make
the neuromuscular demands of these
runs very low.1
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

< 35
S1: Introduction session
Table 2
• Low-intensity running related to sensations (6-8’) Example of session
details of the
• Hip mobility + Running drills
quadriceps injury
• Agility closed-drills sequential RTP load
progressions.
• Functional work (without the ball)
• Type #1: 2x 4-min set: 6x 20s (slalom run 45° 80m) /20s (jog) (TD > 14.4 km/h ≈ 1000m, MaxV < 16 km/h).
• Cool down (3-5’)

S2Q:
• Monitoring (1): 4-min run at 12 km/h
• Hip mobility + Running drills
• Agility closed-drills (quality)
• Type #6: Mechanical work (45-90°): 6x 5+5m 45° CODx1 / 6x
5+5m 90° CODx1 (r: 45s between reps)
• Functional work with the ball (sensations)
• Type #1: 1 x 4-min set: 10s (slalom 45m) /10s (passive) (>
19.8 km/h ≈ 250m, MaxV < 22 km/h)
• Cool down (3-5’)
S3Q:
• Hip mobility + Running drills
• Agility closed to open-skills + Technical work
• Type #6: Mechanical work (45-90°): 2x 5+5+5m
45° CODx1 / 2x5+5+5m 90° CODx2 (r: 45s between
repetitions)
• Technical work with Metabolic component
• Type #6: Mechanical work (130-180°): 4x5+5m 130° CODx1
/ 4x5+5m 180° CODx1 (r: 45s between reps)
• Technical work with Metabolic component
• Cool down (3-5’)

S4Q-WD:
• Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality)
• Monitoring (2): 4 straight-line high-speed runs(box-to-box),
70m in 13s, 30-s passive recovery (> 19.8 km/h ≈ 200m)
• Technical work: spreading, being orientated, controlling +
passing backwards, inside, forwards
• I. Type #6, Mechanical work: 5+10m CODx1 + Finishing on
small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
• II. Type #2/4: Specific WD Mechanical work: 2x 3min 30s-
set: 6 x ≈10s (specific) /≈25s (walk)
S4Q-CM:
• Mobility + Technical work (short pass/volley)
• Running drills + Technical work (control/pass)
• Agility (<10m) + decision (quality)
• Monitoring (2): 4 straight-line high-speed runs(box-to-
box), 70m in 13s, 30-s passive recovery (> 19.8 km/h ≈
200m)
• Technical work: COD with the ball, being orientated,
repeating short passes, playing between 2 lines and
behind the defensive line
• I. Type #6, Mechanical work: 5+5+5m CODx2 + Finishing
on small-goal, 2x 45°, 90°, 130°, 180° (r: 45s between reps)
• II. Type #2/4: Specific CM Mechanical work: 2x 2min 55s
set: 5 x ≈10s (specific) /≈25s (walk)

S5Q-WD and S5Q-CM: in addition to taking part into possession games (without goal keeper) and game situations (with goal keepers)
with the team as jokers/floaters initially, we recommend players to perform some additional acceleration/speed work with specific
movement patterns of high quality (Type #6) including some kicking exercises (long balls and shoots). S4Q-WD drills with a blue
background refer to the drills shown in Figure 1, right panel.

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

Figure 3
Schematic illustration
of each of the Type #2
sequence described
in Table 1 for session
S4HS-WD, S4HS-CM,
S4Q-WD and S4Q-CM.
v

36

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
MONITORING THE RTP
PROCESS IN THE FIELD
The monitoring of the responses
to these types of RTP sessions is
performed using both objective and
subjective measurements. More
specifically, toward the end of the
sequence progression, as a part of one
of the specific session, we conduct
a standardized running test9 (4-min
run at 12 km/h where HR response is
monitored in relation to historical data
and used as a proxy of cardiovascular
fitness, followed by 4 x 60m straight-
line high-speed runs where both stride
balance and running efficiency are
examined via accelerometer data10)
(See Table 1, e.g., green fonts, session
S2HS and S3HS or S2Q and S4Q). Daily
wellness assessment and medical
screening are conducted daily to guide/
adjust the loading of each session.
CHAPTER 2
37
KEY MESSAGES IN RESTORING
PLAYER’S SPECIFIC FITNESS
AND PERFORMANCE CAPACITY
DURING RTP
1. Consider the muscle injury type
as a guide for RTP progression,
e.g. Hamstring muscle requires
more progressive loading of HSR,
whereas Quadriceps muscle
likely requires greater focus on
HIA progressions and loading
2. Individualise further, the target
physical loads (in terms of both
volume and intensity, Figure
1 right panel) and technical
demands based on the players’
position on the field (using
individual data if possible and
knowledge of his playing style).
3. Facilitate players transition from
individual to team work while
adjusting the initial team sessions
(individual warm-up, extra
conditioning post session, and
more importantly playing as joker
during game-based sequences).
4. Monitor internal load to
determine how the player is
coping with these demanding
final sessions before returning to
competitions
5. Consider the players’
psychological readiness to a) re-
join the team and b) return to full
match-play
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.4.1

REGENERATIVE AND BIOLOGICAL

TREATMENTS FOR MUSCLE
INJURY
Despite the substantial regenerative potential that skeletal muscle possesses in
the form of its own stem cells, injured skeletal muscle still heals, like most of our
tissues, by a repair process, not by complete regeneration. Thus, the healing will
result in the formation of non-functional scar tissue.40 The outcome of this repair
process is that the ruptured skeletal muscle fibers remain terminally separated
by the scar tissue that has formed at the site of the injury, i.e. inside the injured
skeletal muscle.40
— With Tero AH Järvinen, Haiko Pas and Jordi Puigdellivol

38 Few tissues, such as bone, can heal by
a regenerative response, i.e. the healing
tissue produced is identical by structure
and function to the tissue that existed at
the site pre-injury. Therefore, intensive
research efforts have been aimed at
finding ways to stimulate skeletal
muscle regeneration and converting the
skeletal muscle repair process to the
regenerative one.40
Regenerative medicine is an exciting
field of translational research in tissue
engineering and molecular biology that
deals with the “process of replacing,
engineering or regenerating human
cells, tissues or organs to restore or
establish their normal function to pre-
injury level”. Regenerative medicine
holds the great promise of engineering
damaged tissues and organs by using
stem cells or stimulating the body’s own
repair mechanisms to functionally heal
(regenerate) injured tissues or organs,
better and faster than the body´s own
healing response.40
to treat sport injuries, especially acute
skeletal muscle ruptures. In addition,
Actovegin® has been claimed to have
oxygen-enhancing capacity, i.e. to
improve the athletic performance.
CLINICAL EVIDENCE
In acute skeletal muscle injuries (or
any other injury), only anecdotal
evidence exists for Actovegin,1,2 and
there is no experimental or clinical data
available to prove its efficacy. The only
clinical trial in sports medicine has
shown that Actovegin® is not ergogenic
(performance-enhancing) and does not
influence the functional capacity
of skeletal muscle.3
RECOMMENDATION
Not recommended
NSAIDS - NON-STEROIDAL
on ability of the injured muscle to contract.4,5
Furthermore, NSAIDs do not delay myofibre
regeneration.6
CLINICAL EVIDENCE
Three placebo-controlled, randomized trials
have assessed the effects of NSAIDs on
human skeletal muscle injury and a large
number of studies have assessed their
efficacy in mild “skeletal muscle injury”
i.e. in delayed-onset muscle soreness
(DOMS).7 In less severe type of muscle
injury (DOMS), a short-term use of NSAIDs
resulted in a transient improvement in the
recovery from exercised-induced muscle
injury.8,9 More recently, NSAIDs were shown
to enhance skeletal muscle regeneration
and remodeling in young humans with
skeletal muscle injury.9 However, NSAIDs
did not accelerate the recovery from severe
hamstring injury.10
RECOMMENDATION
Recommended in acute phase as well

As some regenerative medicine products

are in clinical use and are being offered
to football players, we will review the
scientific evidence supporting their use
in injured athletes as well as provide
evidence-based recommendations for
their usage.
ACTOVEGIN
BACKGROUND
Actovegin® is a deproteinized
hemodialysate of ultra-filtered (<6
kDa) calf serum from animals under 8
months of age. It has been used widely
ANTI-INFLAMMATORY as in DOMS. Care must be taken with
prolonged or frequent use of NSAIDs
DRUGS however, due to their potential gastric
(and other) side-effects.
BACKGROUND
Non-steroidal anti-inflammatory drugs
(NSAIDs) are a class of drugs that provide
analgesic (pain-killing), antipyretic (fever-
reducing) and anti-inflammatory effects.
NSAIDs are widely used in athletes to
provide pain-relief after injuries. NSAIDs
have been extensively studied on injured
skeletal muscle. Short-term use of different
NSAIDs in the early phase of healing leads
to a decrease in the inflammatory cell
reaction, with no adverse effects on the
healing process or on the tensile strength or

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
CORTICOSTEROIDS
BACKGROUND
Corticosteroids are a class of steroid
hormones that are involved in a wide
range of physiological processes, among
them the suppression of inflammation.
Corticosteroids (either orally or by local
injection) have been administered in acute
skeletal muscle injuries with the aim of
alleviating the inflammatory response in the
early phase of healing. Experimental studies
have reported delayed elimination of the
hematoma and necrotic tissue, retardation
of the muscle regeneration process and,
ultimately, reduced biomechanical strength
of the injured muscle with the use of
glucocorticoids in the treatment of muscle
injuries.4-11
CLINICAL EVIDENCE
No clinical studies addressing the effect
of corticosteroids on injured skeletal
muscle exist.
RECOMMENDATION
Not recommended (based on vast
experimental data showing significant,
almost complete, retardation of the
healing process).
CHAPTER 2
PRP
BACKGROUND
Platelet-rich plasma (PRP) is a concentrate
of platelet-rich plasma protein derived from
whole blood by centrifugation that removes
red blood cells (and immune cells). PRP
has an increased concentration of plasma-
derived growth factors and platelets, which
in turn, contain a large number of growth
factors.12 In vitro- as well as experimental
studies have indicated that PRP could
enhance the recovery of different sports
injuries, among them, skeletal muscle
ruptures.13
CLINICAL EVIDENCE
Two placebo-controlled, randomized
controlled trials (RCTs) on athletes with
acute skeletal muscle injury have shown
that PRP has no beneficial effect on any of
the recovery parameters (return to play, rate
of re-injuries).14,15 Recent meta-analyses
have shown that PRP does not shorten
“return to play”-time nor reduce the
recurrence rate of the injury.16,17 Furthermore,
it was recently shown in experimental
skeletal muscle injury-model that both PRP
and early rehabilitation accelerate skeletal
muscle regeneration, but they do not
have any synergy when both treatments
are prescribed together.18 This may be the
explanation why PRP has failed in the RCTs
to stimulate skeletal muscle regeneration in
athletes with an injury.18
RECOMMENDATION
Not recommended
LOSARTAN 39
BACKGROUND
Losartan, an angiotensin II type I receptor
blocker , is one of the most commonly
used drugs for hypertension. Some RCTs
carried out in the cardiovascular medicine
provided “hints” that losartan could also
inhibit fibrosis and scar formation, in
addition to its blood pressure-lowering
function. Furthermore, early experimental
studies suggested that Losartan could
inhibit growth factor-β1 (TGF-β1)-driven
scar formation. As TGF-β1 is the growth
factor responsible for fibrosis and scar
formation in injured skeletal muscle, there
has been interest to use it as inhibitor of
scar formation in injured skeletal muscle.
Experimental research has indeed indicated
that losartan can stimulate skeletal muscle
regeneration and inhibit scar formation
after injury.19-21 Despite enthusiasm towards
losartan, one needs to note that more recent
research has proven that losartan is not an
inhibitor of TGF-β1.
CLINICAL EVIDENCE
Losartan has been recently studied on
injured human skeletal muscle in RCT.22 No
effect on regenerating skeletal muscle was
identified for Losartan after DOMS-type
of mild skeletal muscle injury in the RCT.22
Furthermore, losartan has also been tested
in large RCTs as an anti-fibrotic molecule in
other human diseases where fibrosis and
scar formation take place. Losartan has
failed in all these RCTs to inhibit and fibrosis/
scar formation.23-25
RECOMMENDATION
Not recommended
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
40 STEM CELLS
(MESENCHYMAL)
BACKGROUND
Stem cells are cells with the ability to
differentiate into a multitude of cell types.
Among the different populations of stem
cells, mesenchymal stem cells (MSCs)
have received most interest in sports
medicine. MSCs are stem cells that are
able to differentiate into cells of one germ
line, mesenchyme, i.e. to osteoblasts
(bone), chondrocytes (cartilage), tenocytes
(tendon), myocytes (skeletal muscle) or
adipocytes (fat).26
The mode of action of MSCs is considered
two-fold: firstly, their differentiating potential
would theoretically allow them to replace
lost or injured tissue. 26-28 Secondly, MSCs
produce a vast number of growth factors
that could augment tissue regeneration. In
addition, MSCs have an immunoregulatory
effect (suppression of chronic, detrimental
inflammation) on their environment.27-28
CLINICAL EVIDENCE
To our knowledge, stem cells of any
kind, have not yet been tested to treat
muscle injuries in clinical trials. Some
sports medicine organizations, such as
The Australian College of Sports and
Exercise Physicians, strongly advise
against the use of stem cell-therapies,
and there is no definitive evidence
ruling out a potential increased cancer
risk with these cell therapies.
RECOMMENDATION
Not recommended (based on total lack
of clinical evidence)
CHAPTER 2
EXTRACORPOREAL SHOC-
KWAVE THERAPY (ESWT)
BACKGROUND
Extracorporeal shockwave therapy
(ESWT) is based on abrupt, high
amplitude pulses of mechanical energy,
similar to soundwaves, generated by
an electromagnetic coil or a spark in
water. “Extracorporeal” means that the
shockwaves are generated externally
to the body and transmitted from a pad
through the skin. ‘Shock wave’ therapies
are now extensively used in the treatment
of musculoskeletal injuries and have been
advocated also for skeletal muscle injuries.
CLINICAL EVIDENCE
No clinical studies addressing the effect
of ESWT or “shock waves” on injured
skeletal muscle exist.
RECOMMENDATION
Not recommended (based on total lack
of clinical evidence)
HYPERBARIC OXYGEN
THERAPY (HBOT)
BACKGROUND
HBOT is the medical use of oxygen at
greater than atmospheric pressure to
increase the availability of oxygen to the
body. HBOT has been used to treat various
conditions such as gas gangrene, chronic
wounds, carbon monoxide poisoning.
As the supply of oxygen is crucial for the
repair of sports injuries, HBOT has been
advocated for skeletal muscle rupture.
There is indeed preliminary, experimental
evidence supporting the use of HBOT to
treat skeletal muscle injuries.29-33
CLINICAL EVIDENCE
HBOT was shown to improve the
recovery from less severe skeletal
muscle injury, i.e. delayed-onset
muscle soreness (DOMS), in one
randomized controlled trial27, but
another two randomized controlled
trials found no or very little beneficial
effects.34,35 There are no clinical studies
addressing the effects of HBOT on
severe skeletal muscle injuries.
RECOMMENDATION
May have a slight benefit in treating
DOMS, but no clinical studies on
“severe”/”real” skeletal muscle injuries
have been published.
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES
THERAPEUTIC ULTRA-
SOUND (TUS)
BACKGROUND
TUS is widely used in the treatment of
muscle injuries, although the scientific
evidence on its effectiveness is somewhat
vague. The micro-massage produced by
high-frequency TUS waves are proposed
to have analgesic properties, and it has
been proposed that TUS could somehow
enhance the initial stage of muscle
regeneration. However, TUS does not
seem to have a positive (muscle-healing
enhancing) effect on the final outcome of
muscle healing in experimental skeletal
muscle injury models.36-38
CLINICAL EVIDENCE
Randomized controlled trial showed
that TUS reduced pain and improved
recovery after DOMS.39 No clinical study
are available on TUS on severe skeletal
muscle injuries.
RECOMMENDATION
Recommended for DOMS-type of
injuries, no evidence available to
support the use in severe skeletal
muscle injuries.
CHAPTER 2
EARLY
REHABILITATION
BACKGROUND
A series of experimental studies have
established that early, active mobilization
started after a short period immobilization/
rest (duration: inflammatory period of
healing) is ideal therapy for injured skeletal
muscle.40
CLINICAL EVIDENCE
A recently published randomized
controlled trial showed that early
rehabilitation produces significantly
faster return to sports than delayed
rehabilitation protocol without any
significant risk of re-injury.41
RECOMMENDATION
Recommended. Athletes should
be encouraged to start early, active
rehabilitation immediately after the
inflammatory period (3 – 5 days). Safe
and effective treatment protocols have
been developed and scientifically
tested (proven to work without
increased risk of re-injury) for certain
muscle groups such as hamstrings, calf
and quadriceps muscles.41-43
TAKE HOME MESSAGE 41
Despite the vast amount of scientific
interest and financial resources devoted
to the field of regenerative medicine,
most of the recent and the promising
innovations have failed to live up to their
billing in clinical trials. For some of the
new, basic research-derived innovations
such as stem cells, the jury is still out
as they have not progressed from pre-
clinical studies to clinical studies, and as
such fail to truly address their potential
clinical value in the care of injured
athletes.
We still rely on rehabilitation protocols
started early after the injury in the
treatment of the ruptured skeletal
muscle. What is both encouraging
as well as helpful, is that substantial
scientific progress has been made in
terms of validating early rehabilitation
as the gold standard therapy for injured
skeletal muscle. Standardized, “battle-
tested” rehabilitation protocols have
been introduced to the field recently
to provide a framework for safe and
efficient rehabilitation.41-44 By adhering
to these protocols, the injured athletes
can recover from serious skeletal
muscle injuries as fast and effectively as
possible.41-44
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

2.4.2

SURGERY FOR MUSCLE

INJURIES
When dealing with muscle injuries, the main principles of non-operative treatment
should be used as a common guideline. There are, however, more severe muscle
injuries in which surgical treatment should be considered. Especially in athletes,
but also in other physically active people, if misdiagnosed and/ or improperly
treated, a complete or even a partial muscle rupture can cause considerable
morbidity and lead to decreased performance.1,2
— Lasse Lempainen and Janne Sarimo

42 The indications for surgery in muscle
injuries are not always generally
acknowledged. However, there are
certain clear indications in which surgical
treatment is beneficial even though no
evidence-based treatment protocol exists.3
These indications include the athlete with
a complete rupture of a muscle with few
or no agonist muscles (e.g. hamstring,
pectoralis, adductor), or a large tear where
more than half of the muscle is torn.
Furthermore, surgical treatment should
be considered if an athlete complains of
permanent extension pain (e.g. rectus
femoris) in a previously injured muscle. In
such a case, formation of scar restricting
the movement of the injured muscle has to
be suspected and surgical deliberation of
adhesions should be considered.
In literature, muscle injuries are often
categorized as isolated muscle injuries.
They could however also be considered
as tendinous injuries, as the site of the
rupture often involves both the muscle
and tendon tissue itself, like in the cases
of complete avulsions or central tendon
ruptures.4-6 Early and correct diagnosis, as
well as accurate classification of muscle
injuries, are the basic elements for proper
treatment and recovery from injury.7 The
tendon area involved in the muscle injury
has to be taken into account when making
a decision of possible surgical intervention
and also when deciding the surgical
technique itself.6
In the later section on ‘Specific Muscle
Injuries’ section of this Guide, we and
other experts will provide further
information and guidelines related to the
surgical indications and management of
specific muscle injury types; hamstrings,
quadriceps, adductor and calf.

CHAPTER 2
MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

43

CHAPTER 2
 MUSCLE INJURY GUIDE:
PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

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PREVENTION OF AND RETURN TO
PLAY FROM MUSCLE INJURIES

47

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